Depression

Not a Normal Part of Aging

Depression is a serious concern for anyone, and no less so when a person has diabetes. Studies have shown that if you have both diabetes and depression, you are more likely to have high blood glucose, diabetes-related complications, and a shortened life span. While this may be because seriously depressed people typically don’t take as good care of themselves, researchers think that the link may go beyond that. Fueling their suspicions are the facts that the incidence of depression is higher among people with diabetes than in the general population and that being depressed raises the risk of developing Type 2 diabetes.

Depression is also common among older Americans, and as the U.S. population ages and the incidence of diabetes continues to rise, the number of people dealing with both diabetes and depression is expected to rise, as well. Consider these numbers: In the next 20 years, as the baby boomer generation ages, the number of Americans age 65 and older is expected to double. In roughly the next 50 years, according to Centers for Disease Control and Prevention estimates, the number of people between the ages of 65 and 74 who have diabetes will triple and the number 75 and older with diabetes will increase by a factor of five. Currently, it is estimated that 8% to 20% of older people living independently (not in nursing homes) are depressed, and it is known that people over 85 have the highest suicide rate of any age group. All of these statistics point to the need for effective treatments for depression in older people.

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Depression is not just the normal sad feelings that occur at times of loss, stress, or disappointment. A person who is depressed typically feels deep sadness, feels very little pleasure in life, and may even contemplate suicide.

While the stress of coping with any chronic disease can contribute to depression, researchers are studying what unique aspects of diabetes might account for the high rate of depression among people with diabetes. They are exploring whether, for example, there may be biological factors such as changes in hormone levels that contribute to both diabetes and depression. In the meantime, however, it is known that identifying and treating depression in people with diabetes is possible and important for their overall physical and emotional health, as well as for their diabetes control. This article examines some of the particular stresses that diabetes and the process of aging cause for older people, the link of these stresses to depression, and what can be done to help.

Physical causes and effects

As a person ages, his body inevitably changes. No matter how much exercise he does, his muscle mass decreases, his ability to do strenuous activity declines, his bones become more brittle, and his joints become less flexible. Certainly, getting regular exercise and practicing good nutrition can slow this progression and help compensate for the decline. But to a certain degree, these changes happen to everyone, and the resulting loss of ability may cause or contribute to depression.

People with diabetes have the added stress of knowing that the longer they have lived with the condition, the higher their likelihood of developing diabetes-related complications, such as kidney and eye disease. The aging heart also becomes more vulnerable to the negative effects of diabetes, and many people with diabetes develop cardiovascular disease as they age. It is thought that diabetes complications such as heart disease may also lead to biological changes that cause or contribute to depression, although how they do so is not known.

Some of the bodily changes that occur with aging can have a negative effect on diabetes control. For example, many older people experience hormonal changes that make it difficult for them to notice symptoms of low blood glucose. This raises the likelihood that mild hypoglycemia will turn into moderate or severe hypoglycemia, which is particularly dangerous in older people. Not only can hypoglycemia lead to a fall, but severe hypoglycemia may trigger a heart attack or stroke. Many people also eat less as they age, which also raises the risk of developing hypoglycemia.

Emotional factors

While the link between aging and depression may be partially due to physical changes, it is likely that there is an emotional connection, as well. There are many losses that older individuals must adapt to, and loss is a major psychological cause of depression. Older people may experience the physical changes that accompany aging as a loss of self, possibly feeling that “I’m not the person I was when I was younger.” Physical changes may also mean they are not able to participate as readily in social activities, and so they additionally experience a loss of social contact and friendship. Older people often have other real losses in their lives, such as the deaths of family and friends and the loss of their vocation because of illness or retirement. As older people face their own mortality, anxiety and distress may emerge.

While most older people adapt and thrive in the face of these transitions, some become emotionally overwhelmed and experience persistent sadness. Add to this burden the emotional challenges of diabetes such as fear of complications, resentment over the lifestyle changes that are required to manage it, and stress on relationships, and it is easy to see how diabetes can make a person even more vulnerable to depression. Indeed, one study that looked at the effects of depression and diabetes together found that having both conditions resulted in a higher incidence of disability and complications than did having either condition alone.

Environmental causes

Certain aspects of American culture may also promote depression in older individuals. For example, in today’s youth-oriented Western cultures, which are fast-paced, quickly changing, and dependent on new and advanced technologies that are often difficult for older individuals to master, older people may be mocked and their inabilities, rather than their abilities, highlighted.

Moreover, modern families are commonly dispersed geographically, often leaving older — and younger — people feeling isolated and disconnected from needed support. This environment can make an older person feel out of place and alone in facing the challenges ahead, leading to feelings of hopelessness (“It will never get better”) and helplessness (“There’s nothing I can do to make it better”), both of which are attitudes that underlie depression. Add to this the environmental stresses of diabetes, such as the need for frequent medical visits and the high cost of treating it, and it is clear how having to cope with diabetes may contribute to depression.

Signs and symptoms

When a person has experienced certain symptoms for most of the day nearly every day for at least two weeks, he can be diagnosed with depression. These symptoms include persistent sadness, lack of interest in activities that used to bring pleasure, changes in appetite (eating more or less, sometimes resulting in weight loss or gain), changes in sleeping habits (sleeping more or less), feelings of guilt or worthlessness, low energy, difficulty concentrating or thinking clearly, sluggishness or agitation, and thoughts of death or suicide. A person only needs to be experiencing five of these symptoms to be diagnosed with major depression. People who are experiencing some but fewer than five may be diagnosed with minor depression or a depressed mood that is associated with a major life problem.

Recognizing depression in someone else

For reasons that aren’t fully understood, depressed older people are less likely than younger people to report feeling depressed when asked. However, one sign that an older person may be depressed is a change in his usual activities or a lack of interest in things that used to give him pleasure. For example, if you ask your older neighbor why he hasn’t been gardening as much as usual and he says something like, “I just don’t seem to feel like doing it anymore,” he may be depressed. (Don’t assume, however, that a change in activities is due to depression. Your neighbor may be gardening less because his back hurts or he can’t afford new plants or other materials. Be sure to ask before making any conclusions.)

When assessing mood disorders in older people, health-care professionals often use the Geriatric Depression Scale, a tool specifically designed to screen older people for depression. It consists of anywhere from 5 to 30 yes-or-no questions, such as the following:

1. Are you basically satisfied with your life?
2. Do you often get bored?
3. Do you often feel helpless?
4. Do you prefer to stay at home, rather than going out and doing new things?
5. Do you feel pretty worthless the way you are now?

Of these five questions, a “no” in response to the first question and a “yes” in response to any of the others is worth one point. A score of two or higher indicates that a person may be depressed. However, depression shares many symptoms with other conditions, including dementia. If you are concerned about an older friend or relative’s mood or behavior, share your concerns with that person’s doctor, if possible. In some cases, a primary-care doctor may decide to refer a potentially depressed older person to a psychiatrist for further evaluation.

Treating depression in older people

Medicine and psychotherapy are the two major ways to treat depression in people of any age. Either one can be effective in older people, but in the long run, it’s generally best to have both forms of treatment. Some primary-care providers feel comfortable prescribing antidepressants themselves, while others prefer to refer patients who need antidepressants to a psychiatrist. Unfortunately, some antidepressant medicines can interact with diabetes drugs, interfere with blood glucose control, or cause side effects such as weight gain and lethargy. Drug interactions with other medicines are also a concern, since many older people take numerous medicines. Additionally, the cost of medicines must be considered when prescribing them for a person on a fixed income.

When prescribing antidepressants, many health-care providers start a person on a low dose of medicine and slowly increase it to an effective dose. This helps to lower the risk of serious side effects. How long a person continues to take antidepressants once an effective dose is reached is a decision to be made by that person and his physician. However, some studies have suggested that older people are more likely than younger people to have a recurrence of depression if their medicine is stopped altogether. For this reason, physicians often continue to treat older people with a low dose of antidepressants even after they report feeling better. Having a depression care manager on your health-care team to provide education, emotional support, help with solving problems, and reminders to take any prescribed antidepressants can also be an effective way to prevent a recurrence of depression.

As mentioned, psychotherapy is also helpful for dealing with depression. Some therapists focus on thoughts, others on feelings, and still others on interpersonal relationships, day-to-day problems, or issues from the past. The key is to find someone with whom you feel comfortable sharing your thoughts and feelings so that honest communication can take place. While it is often believed that older people prefer medication to psychotherapy, research shows the opposite is true: Older people are accepting of therapy and at times even prefer it to treatment with medicine.

There are also some things a depressed person can do to counteract his depression. Regular physical activity, such as a daily walk, has been shown to improve mood. People who feel depressed because they’ve become weaker and less able to function independently may want to visit a physical or occupational therapist to build strength and endurance and to identify safe ways to stay active. Spending more time with friends and family and doing activities that used to be pleasurable, even if a person doesn’t feel like doing them, can be helpful as well: Sometimes emotions respond when behaviors are changed first.

Since the physical and mental health of older people are inevitably linked, any treatments for physical or mental health problems should be coordinated and integrated with each other. Many experts recommend that older people receive regular comprehensive assessments by their primary-care providers, which should include assessments of their mood, gait and balance, ability to think and plan, ability to function independently, and quantity and quality of personal relationships. Having this information allows a physician to tailor a person’s treatment to his needs. For example, if a person is having problems remembering or planning ahead, his diabetes treatment regimen may need to be simplified, or a caregiver may need to take over certain tasks.

How to get help

If you think you or a loved one might be depressed, the best place to start is to talk with your family physician. You can’t assume that your physician routinely screens for depression, so if you think you might be depressed, bring up the subject yourself. Similarly, if you suspect a loved one is depressed, tell him that you’re concerned about his emotional health and would like to discuss the matter with his health-care provider. Your local Mental Health Association or Office for the Aging can also be a good resource for information to help manage depression. (Contact information for local organizations can be found online or in the phone book.)

The most important steps are to notice when changes occur in your or a loved one’s emotional or mental state, to explore whether they might be due to depression, and to reach out for information and support.

Depression and diabetes are both potentially disabling illnesses, and older people are at high risk for both. But with appropriate interventions and ongoing care, both can be controlled and hope restored for a better quality of life.

Dr. Trief is the Senior Associate Dean for Faculty Affairs and Faculty Development and a Professor in the Departments of Psychiatry and Medicine at SUNY Upstate Medical University in Syracuse, New York.

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